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News From ACFAS

Submit Your ACFAS 2022 Manuscript
You still have until August 11 to submit your manuscript for the 80th 2022 Annual Scientific Conference in Austin!

Submit your research now to be included in this year’s Manuscript Competition for consideration to give an oral presentation in Austin February 24-27, and manuscript winners will divide $10,000 in prize money.

Visit for policies, author instructions and to submit your manuscript today, but don't wait—the deadline is August 11.
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Surgical Management of the Active Patient is Back in November
Mark your calendar and register now for November’s Surgical Management of the Active Patient course, November 6-7.

This interactive two-day, hands-on course, led by a faculty of skilled arthroscopy surgeons, gives you the opportunity to learn and practice established and cutting-edge techniques in surgery for the foot and ankle as well as the latest techniques in management of the active patient. Highlights include Achilles tendon pathology, 1st MPJ pathology, jones fracture

Learn more about this course and register today at
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Summer Foot Tips with FootNotes
Give your patients summer safety tips with the latest issue of FootNotes—now available in the ACFAS Marketing Toolbox! This edition features:
  • 10 Tips for Healthy Vacation Feet: 10 tips for happy vacation feet.
  • Eliminate Achy Feet During Pregnancy: With helpful hints for expectant mothers, we’re looking at ways to keep feet pain-free throughout pregnancy.
  • Foot Safety for Home Projects: As many people are tackling home projects, we highlight the dangers of some popular home projects and how to keep them safe to avoid potential injuries.
This edition is here for you to use as you wish and help maximize your reach with patient education and marketing your practice. Add your practice information to the customizable second page and keep copies in your office, post it to your practice website and share it on your social media accounts.

Get the latest issue and access more free tools to help ramp up your practice marketing efforts at
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Foot and Ankle Surgery

Assessment of Heart Rate Variability in Subjects With Type 2 Diabetes Mellitus With and Without Diabetic Foot
A study sought to use heart rate variability (HRV) analysis to rate the degree of alteration of sympathovagal balance in patients with diabetes mellitus with diabetic foot and in controls lacking diabetic foot versus a population of healthy subjects and the possible correlation of HRV parameters with inflammatory markers and endothelial dysfunction indices. Sixty-three patients with diabetic foot, 30 patients with diabetes and without ulcerative complications and 30 patients without diabetes were enrolled in the Internal Medicine with Stroke Care ward and of the diabetic foot outpatient clinic of P. Giaccone University Hospital of Palermo, Italy, between September 2019 and July 2020. Patients with diabetic ulcers exhibited lower mean diastolic blood pressure values than healthy controls, lower Mini-Mental State Examination scores corrected for age, lower serum levels of omentin-1, lower reactive hyperemia index (RHI) values, higher body weight values and comparable body height values, high frequency (HF) and low frequency (LF) ratio values. Also noted was a negative correlation between the RHI value and HRV indices and the expression of elevated parasympathetic activity in patients with diabetic foot and a statistically significant positive correlation with the LF/HF ratio and the expression of the sympathovagal balance.

From the article of the same title
Cardiovascular Diabetology (07/14/21) Vol. 20, No. 142 Tuttolomondo, Antonino; Del Cuore, Alessandro; La Malfa, Alessandro; et al.
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Can Achilles Tendon Xanthoma Be Distinguished from Achilles Tendinopathy Using Dixon Method MRI? A Cross-Sectional Exploratory Study
Research aimed to determine whether analysis of separated fat and water magnetic resonance images (MRIs) could distinguish xanthomatic from nonxanthomatic Achilles tendons by measuring intratendinous fat content. The authors conducted bilateral MRI scans of Achilles tendons from 30 participants, including 10 with Achilles tendon xanthoma, 10 with Achilles overuse tendinopathy and 10 healthy controls. All subjects were scanned for total lipid content using the Dixon method of fat and water signal separation. Achilles tendon xanthomas had more fat and water content than the tendinopathy and control groups. Ultrasound tissue characterization exposed worse tissue organization in Achilles tendon xanthoma tendons versus Achilles tendinopathy, but showed largely overlapping distributions. Achilles tendon xanthoma tendons were also significantly thicker than the tendons of the other two cohorts, on average.

From the article of the same title
BMC Musculoskeletal Disorders (07/16/21) Vol. 22, No. 627 Zahradnik, Thomas Michael; Cresswell, Mark; Squier, Kip; et al.
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Longitudinal Validity and Minimal Important Change for the Modified Lower Extremity Functional Scale in Orthopedic Foot and Ankle Patients
A study was held to evaluate the longitudinal validity including responsiveness and test-retest reliability of the revised 15-item version of the lower extremity functional scale (LEFS) and to characterize the minimal important change (MIC) of the modified LEFS in a generic cohort of orthopaedic foot and ankle patients who had surgery. Responsiveness, effect size and standardized response average were measured by determining the score change between the baseline and six-months administration of the LEFS from 156 patients. No significant difference was observed between preoperative and postoperative scores, and effect size and standardized response mean were low. The LEFS' test-retest reliability was satisfactory, while the intraclass correlation coefficient was 0.85. The lack of significant score change prevented the estimation of MIC value. The modified LEFS indicated relatively low longitudinal validity in a group of generic orthopaedic foot and ankle patients, suggesting it might not be the best tool for assessing clinical change over time for these patients.

From the article of the same title
Journal of Foot & Ankle Surgery (07/16/21) Saarinen, Antti J.; Bondfolk, Anton S.; Repo, Jussi P.; et al.
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Practice Management

How to Eliminate Sneaky Sources of HIPAA Violations in Your Marketing Efforts
To avoid Health Insurance Portability and Accountability Act (HIPAA) violations, physician practices should concentrate on less obvious areas like marketing. Basic steps to prevent marketing-related violations include ensuring that the practice's website is HIPAA-compliant, with the accidental compromise of patient information one hazard of marketing content creation. Practices should consider all the places on their sites that ask a person to submit information, making sure not to expose Protected Health Information (PHI). Collecting information within the bounds of HIPAA compliance requires obtaining express written consent from patients; confirming that information is being submitted in a safe and encrypted manner; identifying who will retrieve that information and anyone who could potentially access it; and ensuring that the data is stored in a location or on a server that satisfies HIPAA standards. The security of the server should also be verified with the website host, and practices should revoke credentials and access for anyone who does not have an essential need for the information.

A second step is for practices to consider their data collection tools to make sure they do not run afoul of HIPAA. It makes sense to select tools that are specifically designed for health organizations, while signing a business associate agreement (BAA) with any vendors is also a good way for practices to protect themselves. A third tip is to think through lead generation programs. Practices that work with people outside their health organization, like marketing agencies, are likely sharing significant information with them. Even data that may not seem like PHI, like phone numbers linked to a name, can be considered PHI under HIPAA. A BAA can help ensure that these external parties are familiar with HIPAA compliance.

From the article of the same title
Physicians Practice (07/20/21) Sauceman, Rachael
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Top Five Tax Strategies for Your Medical Practice
A number of tax strategies can benefit medical practices, starting with proper entity selection. Factors that play into this choice include the amount of revenue the practice is generating; whether it has employees; whether the physician needs to protect any assets or themselves; which state the practice is in; its costs and managerial responsibilities; and whether the practitioner is seeking more permanence or transferability. The easiest and most direct way to reduce taxes is to contribute to a pre-tax retirement plan, although there are limits to contributing amounts based on the type of plan and whether the holder is the employee or the employer. Practices with a large inventory of medical equipment can also lower their taxes by using the equipment in a gift-leaseback, which effectively replaces the current salary of a family member. Hidden business deductions are another tax-reducing vehicle, and examples include the Augusta Rule (the 14-Day Rental Rule); the Home Office deduction; deductions of mileage costs for travel between home office and another practice location such as a hospital or clinic; and Health Savings Accounts. Finally, a cost segregation study might be a viable tax-saving strategy if the physician owns the building the practice is in.

From the article of the same title
Medical Economics (07/13/21) Gallati, Alexis E.
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Health Policy and Reimbursement

Americans' Medical Debts Are Bigger Than Was Known, Totaling $140 Billion
New research published in JAMA finds that Americans owe nearly twice as much medical debt as was previously known, and that amount has become increasingly focused in states that do not participate in the Affordable Care Act's Medicaid expansion program. The study estimated that collection agencies held $140 billion in unpaid medical bills in 2020, compared to $81 billion in 2016. Moreover, roughly 18 percent of Americans hold medical debt in collections. Unpaid medical bills became the largest source of debt owed to collections agencies between 2009 and 2020, while overall debt from medical and other bills fell as the economy resurged from the Great Recession. Although Medicaid tends to cover the kinds of medical bills that result in outstanding debts, Stanford University's Neale Mahoney was shocked to learn that differing state policies appear have caused growing inequality in medical debt. Last year, Americans in states that did not expand Medicaid owed an average of $375 more than those in participating states, an approximately 30 percent increase from the gap that existed the year before the expansion was enacted.

From the article of the same title
New York Times (07/20/21) Kliff, Sarah; Sanger-Katz, Margot
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US Proposes Raising Penalty for Hospitals That Don't Publish Prices
The Biden administration has proposed hiking penalties for larger hospitals that do not publicize their prices and cracking down on the use of special coding within hospital webpages that bars Google and other search engines from displaying price pages in search results. The US Centers for Medicare and Medicaid Services aims to increase fines as high as $2 million a year for large hospitals that do not make prices public, up from the $109,500 maximum a year per hospital under current rules. Data from Turquoise Health indicates no usable pricing data from 32 percent of 4,885 acute care, children's or rural primary-care hospitals as of July 19, while another 10 percent of these hospitals have prices that fall short of requirements. The proposal would also require hospitals to guarantee that prices can be accessed by automated searches and that files can be directly downloaded. "With today's proposed rule, we are simply showing hospitals through stiffer penalties: concealing the costs of services and procedures will not be tolerated by this administration," said Health and Human Services Secretary Xavier Becerra. The American Hospital Association (AHA) and other trade groups do not welcome the proposal, with the AHA saying interpretation of the rules is uncertain and higher penalties were worrying.

From the article of the same title
Wall Street Journal (07/19/21) Evans, Melanie; Mathews, Andrea Wilde; McGinty, Tom
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Voters Prevail in Missouri: 275,000 to Gain Access to Healthcare
The Missouri Supreme Court has ruled that an additional 275,000 low-income individuals Missourians again qualify for publicly-funded healthcare. Voters successfully supported a state constitutional amendment on the ballot last August to adopt Medicaid expansion. The amendment makes adults between 19 and 65 years old eligible for Medicaid if they constitute 133 percent of the federal poverty level, or about $35,200 for a family of four. It also bans Missouri from effecting work requirements for Medicaid recipients. However, the GOP-controlled legislature refused to implement the amendment, spurring Gov. Mike Parson to ditch the plan. The high court debated whether the 2020 ballot item required lawmakers to appropriate money, which would have violated state law and unanimously agreed against this argument. The justices ruled that new Medicaid recipients would join the current pool of beneficiaries in the state, and lawmakers would have to decide what action to take when the current appropriation expires. This does not mean that newly eligible Missourians can access benefits at once, as Parson in May withdrew federal paperwork that established the enrollment process.

From the article of the same title
NPR (07/22/21) Rosenbaum, Jason; Lippman, Rachel
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Medicine, Drugs and Devices

Drug Distributors and Johnson & Johnson Reach $26 Billion Deal to End Opioid Lawsuits
Cardinal Health, Amerisource Bergen, McKesson and Johnson & Johnson have reached a $26 billion settlement with states over their role in the opioid epidemic. The agreement will see billions of dollars distributed to communities across the United States for addiction treatment, prevention services and other steep expenses from the epidemic. When the settlement is officially finalized, states and thousands of local governments will drop their opioid-related lawsuits against the companies and pledge not to bring future action. A separate deal between the companies and Native American tribes is still being negotiated.

From the article of the same title
New York Times (07/22/21) Hoffman, Jan
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Michigan Medicine Study Finds Similar Health Outcomes in Opioid and Non-Opioid Post-Surgery Medications
Recent research from Michigan Medicine at the University of Michigan Health found post-surgery opioid and non-opioid pain treatments have the same health outcomes, pain control and patient satisfaction. The study involved 22,000 participants from 70 hospitals who received common surgeries from Jan. 1 to Oct. 31 of 2019. Post-surgical medications like ibuprofen and acetaminophen, or non-opioid pain relievers, did not elevate pain levels or reduce patient satisfaction of care and pain relief. Eighty-six percent of the participants were given an opioid prescription and 14 percent received a non-opioid prescription. Out of both cohorts, 82 percent reported high satisfaction with their care and 93 percent said they do not regret their surgery. Participants who had non-opioid treatment were more likely to report no pain within the first week post-surgery versus those on opioids, and were more likely to report the best quality of life after surgery. Twelve percent of both groups experienced an adverse event within 30 days after surgery, showing no difference in potential complications between cohorts.

"This study clearly shows no difference in pain, major adverse events or patient-centered outcomes when opioids aren't prescribed," said Michigan OPEN co-director Mark Bicket. "The growing body of evidence about the risks of opioid medications to the patient, and to others who might misuse leftover pills from the patient's prescriptions, has to be considered together with evidence about their relative effectiveness for pain control."

From the article of the same title
State of Reform (07/13/21) Jones, Patrick
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This Week @ ACFAS
Content Reviewers

Caroline R. Kiser, DPM, FACFAS

Elynor Giannin Perez DPM, FACFAS

Britton S. Plemmons, DPM, AACFAS

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This Week @ ACFAS is a weekly executive summary of noteworthy articles distributed to ACFAS members. Portions of This Week are derived from a wide variety of news sources. Unless specifically stated otherwise, the content does not necessarily reflect the views of ACFAS and does not imply endorsement of any view, product or service by ACFAS.

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